Monday, August 31, 2015

Noticing the ineffectiveness of certain approaches to garnering hospital and doctor compliance with important safety standards (like hand hygiene), Brad Flansbaum offers an intriguing way to improve:

Assemble a moderately sized pod of hospitals, matched on
demographics, payer, SES, bed size, etc., and keep them as
geographically proximate as possible. If they compete, even better.
Have them decide on a monitoring system they will purchase together at a
discount (I hear vendors like big orders). If CMS has a little seed
money sitting in a slush fund, still better. Alternatively, maybe even
condition participation on a half-percent penalty give back from another
program like the HRRP or VBP.

All the institutions must agree on the rules of the multi-year
monitoring project, and each must publish their sum scores in a publicly
accessible database (individuals would be held harmless for this
endeavor). The catch? The bottom performers pay a penalty into a
patient safety fund–one significant enough to make the bean counters
take notice, but not enough to discourage continued participation.

However, there is another catch: CMS cannot touch
the lucre. It funds worthwhile QI efforts of the mini-consortium,
overseen by a self-appointed, representative board and approved by the
Feds.(Restrictions apply, of course, and the headline purchased by the
victors in their local papers cannot read, “Hey losers, you owe us 5%.
Also, before you give us the check, wash your hands. Oh yeah,
prospective patients are forewarned.”)

Oversimplified? Yes. Crazy? No. But you get the picture.

All kidding aside, regardless of how you monitor handwashing
compliance, if penalties translate to individual and hospital hurt,
financial or otherwise, folks must buy in. The guts of any modern day
solution will require technology and upfront costs. Anything less will
lead front-line providers to push back and harbor more ill will against a
regulatory system they increasingly see as suffocating and harsh (read:
n=10 on a core measure). Occasional and mediocre monitoring just won’t
do.

Sunday, August 30, 2015

I've been thinking hard about whether to share what follows. I've finally decided to do so now, at the start of the fall semester, as a form of advice to students and young professionals. The advice is actually quite simple: Learning to write well requires you to be open to honest criticism. It is all right if you don't like how a professor or someone else responds to your writing, but try to put aside your personal feelings and draw whatever value you can from someone who has taken the time and made an effort to be helpful to you. Also, be gracious.

The background is as follows. A junior faculty member at a medical school recently asked me to read and critique a book s/he had published. I am often asked by students and other young professionals to do this, and I am always happy to pitch in, in the hope of being helpful during the formative stages of their careers.

In this case, I felt that the book was not very good. It's not that the ideas it contained were off base. Rather, the writing wasn't persuasive and clear. I wanted to be honest in my critique, but I also wanted to do my best to make the review a good learning experience. So, I actually consulted with a number of senior academic faculty members to get their advice on how I should approach the task. What I wrote is what follows--but then stay tuned for the author's response, and my rejoinder.

Here's my email to the author, with items changed to protect his/her identity:

Thanks so much for sending me your book. I think it is a great concept and, of course, timely. You asked for feedback, so here goes:

I've seen many instances, like this, where the author has a lot of good
things to say, supported by powerful stories. The problem that occurs
is that your own depth of knowledge and understanding of the issues gets
in the way of presenting them to readers
who are not as attuned as you to the issues. Why? In short, because
you put in too much, and it is overwhelming.

I always used to tell my students that everything you write should be
considered an advocacy document. You are trying to persuade the reader
that your stories are apt and compelling, and the generalizable lessons
you draw from those stories are equally apt
and compelling. It is very, very difficult to do this when you are so
close to the subject.

So my short answer to your feedback request is that the book could
have used a major dose of editing, preferably by someone who was not
familiar with the topic. Only that kind of detached observer can tell
you where you have done well and where things
need to be reworked. For example, a story might be compelling to you
because you experienced it; but in the telling the power does not come
through. It might be the story itself, and it might be how it is told.

There is also a serious need to separate your personal journey and
feelings from a more detached presentation of the evidence you bring to
bear in making your points. The reader will know that it is
personal--after all, you wrote the book. But if each
story is made too personal, it loses its power as a potentially
generalizable example.

Beyond the substance, the design and presentation of the paragraphs and
other graphical issues needs major work. The text comes across as
overly dense. Something about the font size and margins and line
spacing and indentation is just wrong--making the book
much harder to read. The publisher should have provided you with
better graphic arts support.

These are general observations. I could best illustrate them to
you if we went through several pages and chapters of the book. I'd
welcome the chance to do that next time I am in your vicinity.

I want to close with both encouragement and a warning. [Name,] you
have the potential to make a big difference in this field because of
your commitment to the issues and sound judgment and passion. But, if
you hope to advance in the academic world, your
finished writing products need to reach a higher level. That's
certainly achievable, but it will take some work and help.

With fond regards,

Paul

--

And now the author's reponse:

Dear Paul,

Thank you for taking time to send your feedback. I will let my current
work (as well as future career work) answer your email but to be very
honest, I am disappointed by your email. Of course not because you
didn’t like the book, the writing style or the way
I choose to generate knowledge — it’s normal that a personal book will
evoke different personal responses. What you find problematic has been a
guide for others.

What disappoints me is the rather linear logic you used to develop and
organize your arguments. I shared your email with my mentors, both whom
are incredibly well respected and successful palliative medicine
physicians in two different settings, and they were
underwhelmed (and actually confused) by the email's lack of
understanding of and sensitivity towards the complexity of clinical
life, aging and policy issues, and health care settings in general,
particularly in the context of advanced illness. They
were also taken back and concerned by the email’s lack of understanding
around systems (ED and hospice), system theory, qualitative methods,
and communication theory.

My own voice will continue to develop, and my mentors and I are on a
mission to make a difference through understanding, learning and change,
rather than endless critique and dismissal of differing points of view
and voices that are always in motion.

Best of luck,

--

To which I felt compelled to reply:

To be absolutely clear, [name], my comments were not
in the least "an endless critique and dismissal of differing points of
view and voices that are always in motion." You asked for an honest
critique of your writing, which is simply what I
offered. If you had just wanted encomiums, you needn't have asked.
This was not a critique of your ideas. I'm sorry either I did not make
that clear, or you did not understand. I offered to illustrate the
points to you in detail and in person, but you have chosen to cast aside
that offer.

Your comment about my lack of "understanding of
and sensitivity towards the complexity of clinical
life, aging and policy issues, and health care settings in general,
particularly in the context of advanced illness" is off base. You know
nothing about my experience or knowledge of those issues. Ditto for my
knowledge of system theory and the like. My last bit of advice to you,
for future correspondence with others, is that you do little in offering
a persuasive retort by attacking the supposed knowledge and experience
of the reviewer.

I'm so pleased you will continue in your efforts to bring greater light to this important field, and I wish you the best.

Saturday, August 29, 2015

Nominations are now being
accepted for the Annual MITSS HOPE Award that recognizes people – patients, families, healthcare
providers, hospitals (or teams or departments therein), academic institutions,
community health centers, grass roots organizations, etc. – who exemplify the
mission of Medically Induced Trauma Support Services: Supporting Healing and
Restoring Hope to patients, families, and clinicians affected by adverse
medical events. The award is sponsored by the healthcare software firm RL Solutions
and the winner will receive a $5,000 cash prize. Nominations are due by
September 25, 2015, and the award will be presented at the MITSS
14th Annual Dinner at the Sheraton Boston Hotel on Thursday,
November 12, 2015, from 5:30 to 9 p.m. For more information
or to nominate someone (self-nominations will be accepted), visit the link above
or call MITSS at 617-232-0090 or e-mail wtobin [at] mitss [dot] org.

Thursday, August 27, 2015

We have a bright new Attorney General here in Massachusetts who has already earned her bona fides with regard to putting the brakes on economically unsupported market power expansion by the local dominant provider network. That corporation, Partners Healthcare System (PHS), has now indicated that its primary expansion activities will be outside of the United States, but that statement hides a bit of misdirection. Indeed, PHS remains focused on maintaining its hold on physician organizations and its overall market share here in the state.

It is on this front that the provider group is engaged in a relationship with one of the country's largest electronic health record companies, Epic. And it is here that the Attorney General should rejoin the antitrust battle--not only in Massachusetts on her own--but in cooperation with Attorneys General in other states. The target, though, should not be the provider groups per se, but rather the EHR corporation.

What we are seeing here is a remarkable reinforcement of mutual self-interest in the behavioral patterns of the two entities. Here's how it works. Partners enters into a contract with Epic for the construction of an EHR for its facilities. The two organizations go to the Partners-affiliated, but independent, medical practice groups and tell them that they have to install the Epic EHR--even if the EHR they have had for years is perfectly adequate for their purposes. If a doctors' practice asks why they can't keep their old system, Epic makes clear that interoperability between its system and the practice's legacy system is not feasible. Meanwhile, to clinch the conversion, Partners also informs the local practices that failure to install the
Epic system will foreclose those practices from participating in the
favorable insurance contracting relationships it enjoys.

It is in this manner that the Epic-Partners actions box out the competition in this market, acting on the pair's mutual self-interest. They are complicit with each other in helping to ensure that PHS keeps its network strong by holding on to physician groups and that Epic expands its market power by expelling established competitors. This may not be your usual type of anti-trust activity, but it is anti-trust activity nonetheless. And you can bet it is happening in other states as well.

In the past, Attorneys General have joined forces on matters of interest to many states--public health, environmental protection, and the like. Here, we have a pattern of behavior that seeks to limit competition in an arena of great importance to the public well-being. I hope that our new AG puts this case on her list of priorities for her term of office and seeks allies from other states to join her.

Wednesday, August 26, 2015

We’d be driving along, and all
of a sudden the passenger airbag would shut off, leaving the passenger
unprotected.

A service attendant mentioned that the on-off switch had nothing to do
with weight. It was based on the amount
of water in a person’s body.

There is no warning
about this shut-off system on the passenger side visor. And, if you check the owner’s manual, there
is nothing about this issue in the opening section’s safety precautions,
although there is material about the speed and force of airbag deployment. Later, embedded on page 42, there is this
advisory if you happen to turn to that page: “If the front passenger’s seat
cushion is wet, this may adversely affect the ability to determine
deployment. If the seat cushion is wet,
the front passenger should stop sitting on the front passenger’s seat. Wipe off water from the seat immediately, let
the seat dry naturally and then check the SRS airbag system warning light.…”

Let’s say
you’ve never noticed this “feature.” You’re driving home from the beach on a
crowded highway at 60 mph with your family in a full car, and the passenger airbag
shuts off. Perhaps you see the shut-off
light suddenly illuminating. How exactly
do you stop the front passenger from sitting in the front passenger’s seat? Perhaps
you don’t even see the shut-off advisory light, in that you are focused on the
holiday traffic. In either case, your
passenger faces an unexpected hazard.

When I brought this to the attention of Subaru, there was no recognition of the danger associated with the design. So imagine my interest when I received the following recall notice from Subaru this week:

SUBARU OF AMERICA, INC. has decided that a defect, which relates to
motor vehicle safety, exists in certain 2012 model year Impreza vehicles
equipped with a capacitance-type occupant detection system (ODS) in the
front passenger seat.

You received this notice because our records indicate that you currently own one of these vehicles.

DESCRIPTION OF THE SAFETY DEFECT AND SAFETY HAZARD
When a right front seat passenger plugs a cell phone or other device
into the accessory power outlet or touches a metal part of the vehicle
that is grounded (such as the seat adjustment lever), the ODS may
erroneously determine that the front passenger seat is unoccupied and
deactivate the front passenger air bag.

Should this happen, the Air Bag Warning Light will illuminate and the
Passenger Air Bag Indicator will illuminate “OFF”, providing a visual
warning that the air bag system is not operating properly. The passenger air bag will not deploy under these circumstances, increasing the risk of injury to a front seat passenger in the event of a crash.

REPAIR
Subaru will replace the ODS Occupant Control Unit in your vehicle with a modified one at no cost to you.

Hmm, I wonder why one defect warrants a recall when the other does not. As I noted back in September:

Many Subaru
owners are outdoor types who will drive home after a jaunt to the beach or a
hike in the wet woods. How many of them
know they are in danger when they do so?

I like my car. I just want to "enjoy life, stay safe, and love every mile."What does it take to get this company's attention?

The search box on this blog (yes, the one up there at the top of the page to the left) is really inadequate, so I decided to send a note to a Google friend, asking him/her to forward it to the right people:

Dear Google,

Your search engine inside of
Blogger is awful. It actually better to search for something on my blog
by using Google search outside of the blog platform than within it.

The
problem with the current situation is that people doing a search within
the platform often can't find things from previous blog posts. They
assume that the search box is just as good as a regular Google search,
but attuned to the specific blog.

Can you please fix this? Or just get rid of the search box on Blogger so people aren't misled.

The reply from my friend:

Dear Paul,

We secretly love getting letters like
this, because it reinforces the truth that Google search is so good,
it's even better than searching within any specific Google product. We
hear the same things about non-Google services like Netflix, that
Netflix users have given up on searching within Netflix and search the
Netflix catalog on Google instead.

Now, we
can't officially say this, and internal politics won't allow us to do
something as drastic (and obvious) as turning off the search within
Blogger. But we know you're right. And we're sort of sorry.

Sincerely,

A Googler who sees enough awareness of this get ignored from the inside
and doesn't know where to send it.

Over two years ago, the folks over at the athenahealth kindly invited
me to submit columns to their Health Leadership Forum, and I have done
so on an occasional basis since them. As I recently reviewed the
columns, I realized that my own thoughts on the topics of leadership and
coaching have evolved a bit, and I thought my readers over here at Not
Running A Hospital might enjoy witnessing the transition. So for the last several
days, I have reprinted the posts from the Forum over here. Comments
are welcome at the original site and here. Today's reprint, with added photos, is the last of this series and is from a post dated July 20 2015, "Do We Really Learn From Our Mistakes?"

It’s
often said that we learn from our mistakes. Indeed, many a business
course in leadership offers that premise as a given. I’ve glibly
repeated this often in my classes, speeches, and advisory work.
“You don’t learn from your successes,” I point out, “but rather from your errors.”

all to easy to be overconfident about our ability to
observe and learn. A leader who ruled his country for more than forty
years put it well: “The truly strange thing in your lives is that you
not only fail, but you fail to learn your lesson . . . No matter how
much your beliefs betray you, this is never accepted by you. You are
distinguished by your inability to recognize the truth, no matter how
irrefutable.”

Wheeler continues:

It one thing to recognize this truth in the abstract, but
it’s another to live by it. The writer was the Libyan leader Mu’ammar
Gaddafi, who several years later refused political asylum even as his
regime was collapsing around him. Gaddafi was captured, beaten, and
killed by rebel forces.

Sometimes our inability to be reflective practitioners derives from
cognitive errors and biases. Because these failures are cognitive, it
is almost impossible to see them happening or, afterwards, to realize
that they have occurred.

Cognitive errors show up in many forms. Of the most common are:

Anchoring: the tendency for your first observation to carry disproportionate weight in your decision-making.

Confirmation bias: often accompanied with
anchoring, our confirmation bias values evidence that seems to support
our view while discounting evidence that is contrary to your view.

Recent experience: Even statistically irrelevant recent events carry more power merely because of their placement in time.

Patterning: We are prone, too, to see patterns that
don’t exist. Our minds like order, and we will assert the existence of
dispositive parameters—even when the actual pattern of events is
totally random.

We teach doctors about these cognitive weaknesses — anchoring,
confirmation bias, and patterning — but we tell them that they are
unlikely to recognize that they are happening. Instead, we need them to
buy into systems of group behavior that protect them from themselves.

An illustrative example comes from Joris Lemson, MD PH.D., medical
director of the pediatric intensive care unit at Radboud University
Nijmegen Medical Centre in the Netherlands. One day, he ordered a dose
of strong medicine for a small boy. The nurse obeyed the order, and the
boy almost died from the choice of medication.

Later, when the doctor confessed his distress to the nurse, she said,
“I wondered about the choice of drugs. If you had been an inexperienced
doctor, I would have questioned the order. But I figured, with your
experience, you would know what you were doing, and so I didn’t say
anything.”

In
relating the story to me, he said, “It was at that moment that I
realized that I needed to be protected from my own mistakes.” He then
instituted a strong training program in Crew Resource Management (CRM).
This set of techniques, derived from military aircraft cockpits, offers
particular help in hierarchical situations. It empowers subordinate
members of the team to interrupt a pilot, doctor, or other chief and
help that person from making a serious error.

Joris is honest about the progress of this effort in his PICU. He
notes improvement and general compliance with the approach and
procedures, but he also notes lapses. For instance, sometimes he as
leader will forget to conduct the debriefing. That’s all right, but not
if the other crew members forget to remind him when it happens. A
tenet of CRM is mutual responsibility and authority: If the chief
forgets to carry out part of the protocol, the others are required to
point this out.

Oddly, those of us in more office-based leadership positions do not
protect ourselves from this kind of error. We might tell people that we
want to hear when we are going wrong, but do we behave in such a way
that those call-outs are encouraged? Do we greet an interruption or
criticism with a gracious smile and a thank-you? Or is our (perhaps
unconscious) scowl of displeasure enough to teach subordinates that they
are proceeding at their own risk by doing what we think we told them to
do?

We need to understand that there is an uneven pattern of power in the
boss-subordinate relationship. Our reports, for good reason, have
learned over the years that the person who points out that the king has
no clothing often ends up on the street or left behind when it comes to
promotions or other career advancement. With the scowl, we cement that
fear into people’s everyday lives.

Michael Wheeler summarizes the issue by saying, “You have to monitor
your own behavior to make sure it aligns with your intentions.”

Tuesday, August 25, 2015

Over two years ago, the folks over at the athenahealth kindly invited
me to submit columns to their Health Leadership Forum, and I have done
so on an occasional basis since them. As I recently reviewed the
columns, I realized that my own thoughts on the topics of leadership and
coaching have evolved a bit, and I thought my readers over here at Not
Running A Hospital might enjoy witnessing the transition. So for several
days, I will be reprinting the posts from the Forum over here. Comments
are welcome at the original site and here. Today's reprint, with an additional photo, is from a post dated June 3, 2015, "Following Through: Create The Right Environment For Learning."

One
of my twelve year old soccer players, Adair, was having trouble
consistently kicking long and accurate through balls. As I watched her,
I noticed that most everything about her body position going into the
kick was fine, but she ended up punching the ball with her foot rather
than following through, or she would cross one leg over the other as she
delivered the kick.

“You need to follow through better, and don’t cross your leg,” I
instructed, to no avail. The pattern of inconsistent, low power kicks
continued, often not leaving the ground, and often not directed at the
target.

In a moment of insight, I remembered that she plays golf. I asked
her, “What does your golf instructor tell you about driving a ball?
Doesn’t he say to think about where your club will end up at the end of
the stroke?”

“Yes,” she said, “the club head should end up high above my head at the end of the swing.”

“Oh my gosh! So I should do the same here?”

“Right,”
I said. “Don’t worry about your foot kicking the ball hard. Just like
in golf: If you try to hit the ball hard, what happens? Your body
loses the natural leverage and balance that makes a swing work well.
Think about where you want your foot to end up after the kick: Up high
and pointing towards your target.”

“I want to try it!” she exclaimed.

We stood about 30 yards apart, and she nailed five, then ten, then
twenty perfect through balls, arching gracefully through the air and
landing directly at my feet.

At our game the next day, Adair used her newly developed skill to
place a 25-yard free kick at an angle from the goal in the upper left
hand corner of the net. She glanced over, flashed a thumb’s up, and
offered a smile that seemed to say, “Look what I can do!” I smiled and
returned the thumbs up. It was her moment of satisfaction and joy.

Privately I thought: It isn’t often that a coach gets such immediate validation of a pedagogical technique.

Adair reminded me of an important lesson from the world’s greatest
basketball coach, John Wooden. He used to say, “You haven’t taught till
they’ve learned.” He meant that if your student wasn’t learning
something, chances are it was due to your failure as a teacher. The
trick is to employ a pedagogical approach that meets the needs of the
student, not the staid patterns of the coach.

Here, I had started with didactic instruction, the least likely way
to help a young player employ and perfect a new physical skill. Is there
little wonder why it failed? It did not fail because of any lack of
intent on Adair’s part. Indeed, she is very well intentioned and
extremely focused on improving—with a desire quite typical of
12-year-old girls who do not want to let their team down.

No, it failed
because her coach was not sufficiently empathetic about her learning
process.

Like the stereotypical American tourist trying to get a
native-speaking person in another country to understand his English, I
was just saying the same thing over and over. In a figurative sense, I
was not paying attention to what she was “telling” me, not in words, but
in the behavioral pattern of her body. Once I woke up and was able to
see how my own stubbornness was interfering with her need to establish a
new conceptual framework for her kick, I could be free to try a new
approach.

As coach, all I needed to do was to help Adair to draw the analogy to
some other part of her experience. Then, the physical concept became
intuitively clear. She could make the connection and apply the
analogous skill effectively and consistently.

I am telling this story in this Forum to help leaders remember that
it is usually not your job to engage in didactic instruction of your
staff. That leaves them as uncreative drones trying to do what you say
rather than employing their broad perceptive powers and inquisitive
inclinations to develop the impetus for change.

Your job is to create the conditions for a learning environment,
having sufficient empathy with your people to understand where they are
in their learning process and to learn what interventions you can offer
that will help them grow and excel.

Don’t lecture. Ask. Listen. Explore. Experiment.

As a leader, you are ultimately a coach. The best coaches let their
players take credit for success. Just stand on the sidelines and smile
when it happens.

Monday, August 24, 2015

Over two years ago, the folks over at the athenahealth kindly invited
me to submit columns to their Health Leadership Forum, and I have done
so on an occasional basis since them. As I recently reviewed the
columns, I realized that my own thoughts on the topics of leadership and
coaching have evolved a bit, and I thought my readers over here at Not
Running A Hospital might enjoy witnessing the transition. So for several
days, I will be reprinting the posts from the Forum over here. Comments
are welcome at the original site and here. Today's reprint, with some small additions, is from a post dated March 24, 2015, "Valuing Introverts."

The Wharton School’s Adam Grant has noted:
“If you look at existing leadership research, extroversion stands out
as the most consistent and robust predictor of who becomes a leader and
who is rated an effective leader.” Writer and introvert-activist Susan
Cain has also pointed out that introverts are often passed over for leadership positions.

While there are notable exceptions, I think that these observers tend
to be correct. I’m not saying things should be this way, but they often
are.

If you are one of those extroverted leaders, you have probably
created a corporate environment that is comfortable to you and other
extroverts. Cain notes the pervasiveness of this phenomenon, saying, “We
have this belief system right now that holds that all creativity and
all productivity comes from an oddly gregarious place. Our most
important institutions are designed for extroverts and their need for
lots of stimulation.”

Given that one-half to one-third of people tend toward introversion,
the lack of work environment that introverts would find comfortable is
deeply troubling. As a leader, though, you have a more serious
problem: Those introverts often have the most helpful insights about
thorny problems or often could say something that could keep you from
making a really bad decision.

Indeed,
your team is much more likely to suffer from groupthink if introverts
don’t feel empowered. They will remain silent while the rest of the
group adopts the opinion of the most dominant people in the group. Your
team will likely suffer from confirmation bias, the tendency to be
anchored by the dominant view and find evidence that supports this
preconceived notion, ignoring that which doesn’t. In short, if you have
created a work environment that denies introverts the opportunity to
participate on their terms, you lose a potential treasure trove of
useful input.

I came to notice this—often too late–during my leadership experience
in several settings of government, the private sector, and health care.
Like many of you, I had been trained to believe that group work would
be the most productive and creative way to scope out problems and
identify solutions. Task forces, white boards, and group facilitators
were the standard package for solving problems at the organizations that
I led.

But privacy and autonomy can be very useful catalysts for innovation
too. “Solitude is a crucial ingredient to creativity,” Cain argues.
“For some people, it is the air that they breathe.” Einstein, (above), is quoted as having said, "The monotony and solitude of a quiet life stimulates the creative mind."

If you wish to avoid groupthink, it may be better to allow your staff
to go out and work alone for some portion of a problem-solving
exercise. There, they can be free from the distortion of group
dynamics.

I understand that this cannot be the sole method of problem-solving.
After all, you need to build a coalition of the entire team to have a
successful implementation—and you certainly want to hear critiques of a
plan from all affected divisions in the organization. But you need a
strategy to engage introverts beyond task forces, group discussions and
other highly social settings.

Another way to engage introverts is to channel introvert
characteristics in your own behavior. Grant writes, “We tend to assume
that we need to be extremely enthusiastic, outgoing and assertive, and
we try to bring employees on board with a lot of excitement, a clear
vision and direction, but there is real value in a leader being more
reserved, quieter, in some cases silent, in order to create space for
employees to enter the dialogue.”

Grant relates the story of the CEO of one Fortune 500 company who has
a policy of silence for the first 15 minutes of meetings. He did not
utter a single word, although he is an extrovert. Grant explains, “He
feels that he has a tendency, once he gets excited about ideas, to run
with them to the point where, at times, it leaves employees feeling like
they weren’t included. So he tries to combat that: ‘I want you guys to
tell me whatever you’re thinking about — suggestions, feedback,
questions — and the floor is yours.’ He listens quietly and takes
notes.”

But one executive’s mindful silence is not enough. You’ll need to
make sure that other extroverts in the room do not dominate. I recall
meetings in which our chief of surgery (no surprise!) would sometimes
try to assert control over a discussion of our hospital’s Chiefs
Council. We needed to make explicit time for, and request comments
from, the less outspoken chiefs of other departments. Luckily, the
chair of the Council, our chief of psychiatry, was a master of calm and
could help assure participation by all.

Cain offers a bit of sage advice to us extroverts, one that is
especially important for leaders: “Have the courage to speak softly.
While Western culture favors the man of action over the man of
contemplation, give introverts the freedom to come up with their ideas.”

Friday, August 21, 2015

Over two years ago, the folks over at the athenahealth kindly invited
me to submit columns to their Health Leadership Forum, and I have done
so on an occasional basis since them. As I recently reviewed the
columns, I realized that my own thoughts on the topics of leadership and
coaching have evolved a bit, and I thought my readers over here at Not
Running A Hospital might enjoy witnessing the transition. So for several
days, I will be reprinting the posts from the Forum over here. Comments
are welcome at the original site and here. Today's reprint, with an added footnote and embedded links, is from a post dated February 5, 2015, "False Memories Generate Persuasive Truths."

There
has been much written lately about the tendency of people to develop
false memories about events they have witnessed or experienced. I’m not
talking about folks who intentionally mislead themselves or others
about a given series of actions or events—perhaps, say, to alleviate
guilt or horror. I’m talking about people who truly, deeply believe
that they saw something occur as they now remember it. Their brains are
incapable of understanding that their views of the events are flawed.

This phenomenon might be one of the highest forms of cognitive
errors, and it raises serious questions for those of us in leadership
roles who like to be, in Donald Schön’s words, reflective practitioners.
Don’s concept was elegant. Over the years, we develop a framework
based on our experiences and observations that guides our actions and
choices today.

A reflective practitioner is one who works within that framework but
who is constantly testing it based on new information. As we learn from
recent events, we reconfigure our world view and adapt our leadership
methods to our newly revised conception. We then attempt to persuade
people in our organizations and those outside that the path we’ve chosen
is one they should join.

But if our memories might be flawed, how do we know that the lessons
we draw from them are likely to be accurate, much less helpful? Should
we try to build in a method of self-correction to help us compensate for
our cognitive weaknesses? After all, our organizations and our people
are counting on us to be analytical, thoughtful, and precise. If the
memories are flawed, won’t our conclusions also be?

We
could answer this by saying to ourselves, “Hey, I do the best I can.
If I miss something important because I didn’t realize that I was
mis-remembering, I’ll make mid-course corrections later. Meanwhile,
I’ll present the facts and figures and my impeccable logic, and the
power of that logic will cause people to follow my lead.”

Many of the best authors in the world presented there, and one
session was called “The Art of the Memoir.” Among the panelists were
Anchee Min (born in China and now in the U.S.); South Africa’s Mark Gevisser; the U.K.’s Brigid Keenan; and Joanna Rakoff from the U.S.

All of these authors had written memoirs, i.e., books about a portion
of their own lives. The conversation turned to the question of how to
assure that a memoir was accurate. It quickly became clear that
narrative was more important than accuracy. Rakoff put it this way: “A
memoir is not what happened. It’s what I wrote about what happened.”
She did not mean that she was intentionally clouding the factual history
surrounding events. She meant that she had to make sense of what had
happened and be able to transcribe it in a way that was useful,
compelling, and entertaining for herself and her readers. In short, she
had to be persuasive.

Gevisser went further along these lines: “The memory only happened
once I found the language for it.” Keenan suggested that finding the
language is an iterative process. Even for someone who has trained
herself to keep daily notes, “The transformation of a journal to memoir
takes about eight drafts.”

What possible lesson can we draw from these authors? To me, they
displayed an acceptance of the likelihood of cognitive errors in their
remembrance of events. Indeed, they considered the existence of a gap
between memory and fact to be an asset. Instead of saying, “Hey, I do
the best I can,” they endorse and cherish the existence of the gap.
Their focus is on creating a narrative that can teach a lesson or
motivate readers.

There is a leadership parallel here. The great leaders are those who
offer a persuasive narrative to their potential followers. The
likelihood of building a coalition in support of a given direction is
directly proportional to the power of that narrative. How is that
narrative most likely to be persuasive?

My friend and colleague James Sebenius, at Harvard Business School,
recently reminded me of important lessons related to persuasion.
Centuries ago, Aristotle suggested that there are three aspects of
persuasion—logos, ethos, and pathos. The tendency of many leaders today
is to rely on logos (logic, reason, and evidence) to motivate their
followers.

Facts certainly have their place, but the other parts of Aristotle’s
equation are equally powerful. Both pathos (connecting emotionally) and
ethos (establishing your good character) are best transmitted by
stories. Vivid and specific language complement logic and evidence.
Stories that reflect the story-teller’s principles and vulnerability
likewise add persuasive appeal.

The authors in Jaipur were, in essence, telling us to channel
Aristotle. Understand that your memories are likely to be flawed, but
confidently use the memories you have. Take the time to draw from them
elements of a persuasive appeal. As the political organizer Marshall
Ganz (and the ancient Jewish philosopher Hillel) would have put it: First share the story of your self. Next, draw connections with your
listeners and help them understand that your story is about “us,” the
organization and its purpose. Finally, create a sense of urgency and
communicate that this a story about “now,” with an imperative for action
today.*

In this manner, false memories will generate persuasive truths.
--
* “If I am not for myself, who will be for me? If I am only for myself, what am I? And if not now, when?” (Pirkei Avot Chapter 1:14)

Thursday, August 20, 2015

Over two years ago, the folks over at the athenahealth kindly invited
me to submit columns to their Health Leadership Forum, and I have done
so on an occasional basis since them. As I recently reviewed the
columns, I realized that my own thoughts on the topics of leadership and
coaching have evolved a bit, and I thought my readers over here at Not
Running A Hospital might enjoy witnessing the transition. So for several
days, I will be reprinting the posts from the Forum over here. Comments
are welcome at the original site and here. Today's reprint (retitled and with the real names included) is from a post dated July 11, 2014, "How I Coach."

In
this season of world class soccer, I hope you’ll forgive a short
autobiographical moment from my most important pastime: coaching girls
soccer. I’ve learned so much from these children over more than two
decades and have put many of those lessons in my book Goal Play!

In fact, my current slogan is, “If you can effectively coach
12-year-olds in soccer, you can run an academic medical center!” This is
not a statement about the comparative emotional ages of doctors and
12-year-old girls: It is a realization about how people of all ages deal
with what is often the distress of learning and how you, as a leader,
can help encourage them to grow as part of a learning organization.

Today’s story is about disappointment, when a member of your team has
failed and feels inadequate to the task at hand. How do you present a
compelling and honest narrative to a discouraged person so that he or
she can move on, gain confidence, and remain a productive and happy
member of the team?

The
setting is a rainy, cold, and muddy soccer game, in which Liisa was playing goalkeeper in the second half of the game and let
the two winning shots get past her. She was greatly discouraged and was
convinced she was accountable for losing the game. She compared herself
to her teammate Abby, who had successfully defended the goal in the
first half, and she went home and told her parents that this would be
her last soccer season. Instead, she would play basketball, a sport in
which she felt more accomplished.

Although I talked to her and reassured her right after the game, I
know that a more persuasive approach might be possible once a few hours
had passed.

Here’s the email I sent:

Dear Liisa,
I know you were so sad after yesterday’s game, and I felt very badly
for you. I tried to cheer you up a bit, but I know it was not the right
time, and I didn’t succeed. Would you mind if I offered some more
thoughts now?

Let me start with the basics: You are a terrific person, a great team
player, and a natural leader among your teammates. Plus, you are an
excellent soccer player and, yes, an excellent goalie. We all, your
teammates and coaches, admire and respect you.

The playing conditions yesterday were awful for you as goalie. In
fact, they were worse for you than for Abby because the field got
wetter and wetter as the game went along. The ball got muddier and
muddier, and it also became more saturated with water. As a result, it
was increasingly hard to hold on to. Also, because of the extra weight,
it had more momentum when it was kicked, making it extremely difficult
to catch or stop.

When you are a goalie, it is easy to remember the balls that get by,
but you forget about all the other times you saved the play and rescued
the team from defensive lapses. You did that plenty of times, plus you
also “directed traffic” from your position as goalie, helping your
teammates respond to and anticipate what the other team was doing. I
will tell you that most goalies your age are not as good as you are on
all of those counts. That is a very special set of skills, requiring
presence and maturity.

The
setting is a rainy, cold, and muddy soccer game, in which Laura (name
changed) was playing goalkeeper in the second half of the game and let
the two winning shots get past her. She was greatly discouraged and was
convinced she was accountable for losing the game. She compared herself
to her teammate Alice, who had successfully defended the goal in the
first half, and she went home and told her parents that this would be
her last soccer season. Instead, she would play basketball, a sport in
which she felt more accomplished.
Although I talked to her and reassured her right after the game, I
know that a more persuasive approach might be possible once a few hours
had passed.
Here’s the email I sent:

Dear Laura,
I know you were so sad after yesterday’s game, and I felt very badly
for you. I tried to cheer you up a bit, but I know it was not the right
time, and I didn’t succeed. Would you mind if I offered some more
thoughts now?
Let me start with the basics: You are a terrific person, a great team
player, and a natural leader among your teammates. Plus, you are an
excellent soccer player and, yes, an excellent goalie. We all, your
teammates and coaches, admire and respect you.
The playing conditions yesterday were awful for you as goalie. In
fact, they were worse for you than for Alice because the field got
wetter and wetter as the game went along. The ball got muddier and
muddier, and it also became more saturated with water. As a result, it
was increasingly hard to hold on to. Also, because of the extra weight,
it had more momentum when it was kicked, making it extremely difficult
to catch or stop.
When you are a goalie, it is easy to remember the balls that get by,
but you forget about all the other times you saved the play and rescued
the team from defensive lapses. You did that plenty of times, plus you
also “directed traffic” from your position as goalie, helping your
teammates respond to and anticipate what the other team was doing. I
will tell you that most goalies your age are not as good as you are on
all of those counts. That is a very special set of skills, requiring
presence and maturity.
Briana Scurry, the goalie for the US national women’s team, was once
asked if she thought about the balls that got by her–and plenty did. Her
answer, “Never! I only think about the ones I stopped. When I plan for
the next game, I visualize success. If another ball gets past me in a
game, I immediately put it behind me and get back to visualizing
success.”
I don’t know if you feel you can do what Briana did, but it is worth thinking about.
It’s ok to feel sad about yesterday’s experience, but you must
believe me that you in no way let anyone down. Your teammates and
coaches understood totally what you were up against, and they admired
you for trying your best. And, after all, isn’t that the most we can
hope for?
So, take yesterday as one of those important learning experiences. When
adversity strikes, cry if you need to, but then walk off with your head
up high, smiling, and say, “I’m a great goalie!” Because, my dear,
Laura, you are. Indeed, you are more than that. You are a great person,
and no one can take that away from you.Fondly, Paul

And here’s how this bright young lady responded:

Thank you very much Coach Paul for this thoughtful
email. I will try to continue visualizing success and put yesterday
behind me. This was a very kind and well thought out email and I
appreciate it very much. See you on Wednesday!!
Thanks again!
Laura

Success! We are reminded by this story that the leader’s most
important attribute is empathy. Let’s employ it to help our team members
visualize success by learning from the failures they encounter.
- See more at: http://www.athenahealth.com/leadership-forum/coaching-through-failure#sthash.9nboA8QN.dpuf

Briana Scurry, the goalie for the US national women’s team, was once
asked if she thought about the balls that got by her–and plenty did. Her
answer, “Never! I only think about the ones I stopped. When I plan for
the next game, I visualize success. If another ball gets past me in a
game, I immediately put it behind me and get back to visualizing
success.”

I don’t know if you feel you can do what Briana did, but it is worth thinking about.

It’s ok to feel sad about yesterday’s experience, but you must
believe me that you in no way let anyone down. Your teammates and
coaches understood totally what you were up against, and they admired
you for trying your best. And, after all, isn’t that the most we can
hope for?

So, take yesterday as one of those important learning experiences. When
adversity strikes, cry if you need to, but then walk off with your head
up high, smiling, and say, “I’m a great goalie!” Because, my dear, Liisa, you are. Indeed, you are more than that. You are a great person,
and no one can take that away from you.

Fondly, Paul

And here’s how this bright young lady responded:

Thank you very much Coach Paul for this thoughtful
email. I will try to continue visualizing success and put yesterday
behind me. This was a very kind and well thought out email and I
appreciate it very much. See you on Wednesday!!
Thanks again!
Liisa

Success! We are reminded by this story that the leader’s most
important attribute is empathy. Let’s employ it to help our team members
visualize success by learning from the failures they encounter.

Wednesday, August 19, 2015

Over two years ago, the folks over at the athenahealth kindly invited
me to submit columns to their Health Leadership Forum, and I have done
so on an occasional basis since them. As I recently reviewed the
columns, I realized that my own thoughts on the topics of leadership and
coaching have evolved a bit, and I thought my readers over here at Not
Running A Hospital might enjoy witnessing the transition. So for several
days, I will be reprinting the posts from the Forum over here. Comments
are welcome at the original site and here. Today's reprint, with some additional embedded links, is from a post dated March 27, 2014, "Knowing When It's Time To Leave."

In a recent article on the HBR Blog Network, Manfed F. R. Kets de Vries asks the question, “How long should a CEO stay in his job?”
He answers by saying, “seven years in probably the period of maximum
effectiveness for most people in what can be a very stressful job.” He
goes further to describe three phases that characterize the tenure of
many CEOs — entry, consolidation, and decline.

He asks, “So what can be done when a CEO starts to decline? The best
scenario, of course, is if that the CEO himself realizes what is
happening, acknowledges his increasing ineffectiveness, and looks for
new horizons when the going is still good. Ideally, that is at the point
when they are in the sweet spot of being at the peak of their
performance, just before decline.”

In my case, I arrived at Beth Israel Deaconess Medical Center in
January of 2002, with the assignment to lead a financial turn-around of
an extremely troubled organization. By September of 2003, we officially
declared the end of the turn-around, as the hospital had returned to
sustained profitability.

Having survived, it was then time to engage in a full-fledged series
of strategic plans—focusing on the three parts of this academic medical
center’s mission–clinical care, education, and research. By engaging
the faculty and staff, we were able to reach a consensus on the overall
direction of the place.

Meanwhile,
due in great measure to the recruitment of Dr. Mark Zeidel as chief of
medicine, we began an intense program in safety and quality improvement.
Mark’s commitment to this journey was soon matched by the other
incumbent chiefs and supplemented by the recruitment of new chiefs of
pathology, radiology, and anaesthesia. My role in this effort was to
initiate unprecedented levels of transparency with regard to clinical
outcomes. Our Board was on board, too, adopting a four-year goal of
eliminating preventable harm in our hospital, and posting on our
corporate website—for the world to see—progress towards that goal.
Every quarter, the actual numbers and types of cases of harm in our
hospital would be made transparent.

In March of 2009, we faced a new crisis as the financial meltdown
occurred in the US economy. Having started the fiscal year with
projections of a $20 million surplus, by mid-year we were instead
looking at a likely $20 million deficit. My COO and CFO recommended
laying off 400 people to balance the budget.

I refused and instead asked people in the hospital to suggest ways in
which they were willing to absorb personal financial sacrifices to help
avoid layoffs. The response—which received national attention—was overwhelming. We not only avoided the layoffs, but we were able to
exempt the lowest paid workers from having to participate in any of the
sacrifices chosen by the others.

In August of 2009—right in line with de Vries’s timetable—I woke up one morning and realized I was tired. I was tired from a job that had extremely demanding physical and psychological components. I was also tired of
the job, having felt that I had done my most creative work. I was ready
for new challenges. In terms of my personal health and well-being, it
was time to leave. Also, it was time to let a new person with more
energy and enthusiasm handle the next stage of challenges facing the
hospital.

But I decided to stay on. Why? Here’s where I let myself be trapped
by the close personal relationships that had grown between the staff
and me. Hospitals are compelling and emotionally complex places, and an
empathic CEO feels the joy and pains of the staff and builds a deep
personal bond with these well intentioned people who devote their lives
to eliminating human suffering caused by disease.

In this case, there was an additional anchor. I felt an obligation
to our generous staff to stay long enough to see the hospital through
its financial crises and to restore the pay cuts and reductions in
benefits that they had voluntary taken. I knew that this new
turn-around effort might last at least another year, and I decided to
commit myself to staying the course.

Sure enough, by the fall of 2010, our fiscal health had been
restored. I was able to restore the cuts in pay and benefits. I was
even able to award everyone with a $500 bonus out of gratitude for all
they had done to help to the hospital and one another.

This was a source of great personal satisfaction for me, but as I
look back on the experience, I realize that it was a mistake to stay
beyond the seven years. While my motivation in staying was not
selfish—it fact, it was just the opposite—it was self-centered. Was I
the only person who could have led the organization through that
recovery? No, there were many able leaders in the hospital who would
have done just fine without me. But my dedication to the staff made me
want to stay long enough to feel that I had delivered the goods to them.

As de Vries suggests, it is at such a moment when a Board needs to
step in. They need to closely monitor not only the performance of the
CEO but his emotional mindset. They must overcome inertia in
governance, the natural reluctance to change horses when the race is
going well. The loyalty and friendship that a Board feels towards a
successful CEO is, ironically, a danger. It leads to complacency on the
Board’s part, particularly during moments of corporate triumph. It is
precisely then that a Board needs to carry out its most important
function—telling themselves and the CEO that it is time for him to move
on.

Tuesday, August 18, 2015

Over two years ago, the folks over at the athenahealth kindly invited
me to submit columns to their Health Leadership Forum, and I have done
so on an occasional basis since them. As I recently reviewed the
columns, I realized that my own thoughts on the topics of leadership and
coaching have evolved a bit, and I thought my readers over here at Not
Running A Hospital might enjoy witnessing the transition. So for several
days, I will be reprinting the posts from the Forum over here. Comments
are welcome at the original site and here. Today's reprint is from a post dated February 7, 2014, "The Wrong Map."

My good friend and negotiation guru Michael Wheeler includes an anecdote in his new book, The Art of Negotiation:
“Many years ago, a military patrol was caught in a fierce blizzard in
the Swiss Alps. The soldiers were lost and frightened, but one of them
found a map tucked in his pocket. After consulting it, the men built a
shelter, planned their route, and then waited out the storm. When the
weather cleared three days later, they made their way back to the base
camp.”

Wheeler continues, “Their commanding officer, relieved that his men
had survived the ordeal, asked how they made their way out. A young
soldier produced the life-saving map, and the officer studied it
carefully. He was shocked to see that it was a map of the Pyrenees
Mountains that border Spain and France, not the Alps.”

He suggests three reasons how the wrong map could help save climbers
lost in the Alps: it rekindled the soldiers’ confidence, provided an
impetus to get moving, and sharpened the soldiers’ awareness.

While
Mike uses the anecdote to draw lessons for negotiators, perhaps it also
offers suggestions to leaders in health care. Their institutions face
formidable challenges, and the way forward is not always clear. They
know that standing still — failing to act — is more dangerous than going
in slightly the wrong direction. But how do you motivate your staff to
take action and deal with the ambiguity of the situation?

The traditional wisdom is that you have to “create a burning
platform.” Such an approach uses the threat of imminent financial
disaster or major loss of market share as an incentive to those in the
organization. Well, maybe. But the problem with a burning platform is
that your people fear that the only way to go as they step off the
platform is down.

Few people want to take accountability for initiative in that
situation. Frankly, most people are risk-averse, and telling them that
the world depends on them for decisive action is not highly
motivational.

So, how do we get people past their natural risk-averse tendency? How
do we suggest to them that any (thoughtful) action is better than
sitting back and waiting? How do we get them moving in a direction that
has some probability of being correct? How do we help them sharpen their
awareness so they are alert to the need for mid-course corrections if
the original path proves to be off target?

What map of the Alps can we offer our staff?
The traditional one is a strategic plan: We engage in a long process
to survey our strengths, weakness, opportunities, and threats. We fan
out through the organization and create working groups to enhance buy-in
of our analysis and the alternatives we choose. We overlay the process
with nifty charts and graphs, careful to include the “levers” that will
make a difference in our financial situation or competitive posture.
Then we assign the strategic initiatives to various inter-disciplinary
groups and create key performance indicators for each division of the
company to measure our progress in carrying out the plan.

It is hard to imagine a less inspirational start to a journey of
change than this kind of centralized, highly numerical, and bureaucratic
approach. Here’s a secret. Every strategic plan I have seen in the
health care world says the same thing: “Let’s focus on what we are good
at that pays us well, where we can gain market share, and do more of
that. For the things we don’t do as well, or where payment is not good,
it’s okay not to grow or even to shrink.”

I’m not suggesting that an organization should avoid a strategic
vision. Indeed, having such a vision is a key role of senior management.
I am suggesting that the way to give your “soldiers” the confidence to
leave the campsite, engage in experiments, take risks, and be creative
does not come from an externally generated strategic process. Instead,
we need to allow confidence-building measures to grow organically from
within the organization.

In previous columns, I’ve talked about the value of the Lean process improvement philosophy in reducing waste,
i.e., improving the operating efficiency in an organization. With the
Lean approach, the front-line staff is empowered, expected and
encouraged to call out problems in the work place. Management is
expected to swarm around those identified problems—in real time—and
invent experiments to test out countermeasures to improve the delivery
of goods or services to the customer.

Well, it turns out that Lean also provides that “map of the Alps” in
an uncertain environment. The “map” here is a general philosophy,
approach, and set of tools that is independent of the actual physical
and competitive work environment. It maintains and enhances our
confidence as a team. The “every person every day” theme of Lean
provides ongoing impetus to keep moving. Finally, knowing that the
organization expects and encourages the staff to call out workplace
waste sharpens their awareness.

The “map” for dealing with the challenges of a health care
institution is being held by every staff person in our organizations.
Our job is to create an environment in which they can feel the map in
their pockets and set off each day in the right direction — to reduce waste, improve efficiency, and deliver better service to patients and families.

Monday, August 17, 2015

Over two years ago, the folks over at the athenahealth kindly invited
me to submit columns to their Health Leadership Forum, and I have done
so on an occasional basis since them. As I recently reviewed the
columns, I realized that my own thoughts on the topics of leadership and
coaching have evolved a bit, and I thought my readers over here at Not
Running A Hospital might enjoy witnessing the transition. So for several
days, I will be reprinting the posts from the Forum over here. Comments
are welcome at the original site and here. Today's reprint is from a post dated December 17, 2013, "Bridging the Gap Between Planning and Reality."

A colleague once said, “Every plan is excellent, until it’s tested. It’s execution that’s the problem.” And so it is.

Clay Shirky wrote an excellent article about the gulf between planning and reality. Although the focus was on the misadventures of Healthcare.gov,
the US government’s insurance exchange website, the broader lessons
that he presents are worthy of consideration in many other settings.

For the officials overseeing Healthcare.gov, the preferred answer
was “Never.” Every time there was a chance to create some sort of
public experimentation, or even just some clarity about its methods and
goals, the imperative was to deny the opposition anything to criticize.

Failure is always an option. Engineers work as hard as they
do because they understand the risk of failure. And for anything it
might have meant in its screenplay version, here that sentiment means
the opposite; the unnamed executives were saying “Addressing the
possibility of failure is not an option.”

Project advocates enter every endeavor with a theory of the case, a
vision of how things should be. But, as my late colleague Donald Schön
noted, reflective practitioners are constantly reviewing the evidence to
modify their framework in response to reality.

A comment on Shirky’s article summarizes this nicely:

“Any personal opinion you had given really doesn’t mean anything.” This is the key principle behind making anything work well — from writing an essay to building a bridge to creating a website. If it doesn’t work, throw out your preconceptions and re-conceive.

There is a cognitive basis for our failure to be reflective practitioners. We are all people of habit. The attributes that permitted us as cavemen to recognize the saber-toothed tiger the second time we saw it and to respond in the appropriate way (“Run!”) work well in the highly simplistic natural world. In a Darwinian sense, we evolved perfectly for that world. We developed a learning style that gave us a competitive evolutionary advantage, a learning style based on memory, stubbornness, and brute force.

But the more difficult world of complex organizations — overladen with political, organizational, and cultural forces and with technological challenges — presents an environment in which those cognitive attributes now present as cognitive errors. We struggle with this. Indeed, as MIT professor Rosalind Picard has outlined, successful learning has three phases: interest, distress, and pleasure.

We feel distress in the second phase because it is during that portion of the cycle that we must overcome our prejudices and develop a new framework within which to proceed. We resist. Sometimes we recognize that we have hit a plateau and need to adopt a new approach to proceed. Sometimes we don’t recognize that our framework is flawed and we uselessly proceed apace, until disaster occurs or a competitor outruns us.

Learning Organizations & Lean Philosophy

Places that are true learning organizations have built in a structure that calls the question early and often. One such structure (but not the only) is offered by the Lean philosophy. By encouraging front-line staff to call out problems they encounter in their daily life, managers are given real-time signals as to flaws in their organization’s processes. The leadership team then visits the sites of the flaws and invents experiments to achieve incremental improvements in work flow. Using the scientific method, those experiments are tested and evaluated, with redesign being a constant part of the process. Lean organizations understand that there is no group of central planners clever enough to design an optimum complex process. Lean leaders do not lack for a strong purpose—indeed audacious goals are favored—but neither do they lack humility.

Lean and other similarly designed organizations can only exist where the senior leadership is a strong advocate for the proposition that reflective practice is the best way to achieve outstanding performance for their customers. The leaders of such organizations embed that modesty and reflection in every aspect of their lives.

I’ve had the pleasure of visiting a number of hospitals that work along these lines. The results are palpable — better service to patients, higher quality, less waste, and more staff satisfaction. Such results are irrespective of the type of payment regime employed to compensate the doctors and the hospital. They are irrespective of the societal form of health care, be it a national public system or a dispersed private pay system.

Such hospitals remain anomalies in their industry, although the number is growing. Adoption tends to center in systems with a strong communitarian spirit, where the trustees and clinical and administrative leaders view their job mainly as providing a public service as opposed to supporting the personal and institutional prerogatives of physicians. Thus, while a few academic medical centers have gotten on board, many have not, trapped by age-old patterns of deference to the doctors. Ironically, in those academic medical centers that have adopted Lean or a similar approach, physicians report tremendous satisfaction from their engagement with process improvement and from the enhanced sense of teamwork with members of the staff throughout the hospital.

The young cadre of rising health care leaders I see when I address clinical and administrative training programs, and when I speak at conferences and in hospital settings, understand that the future is brightest for learning organizations. They thirst for experience in trying out these approaches, and they intend to lead in the manner of reflective practitioners. I say to current health care leaders, when you find one of these rising stars, grab him or her for your place. They are going to teach you something special.

Friday, August 14, 2015

Over two years ago, the folks over at the athenahealth kindly invited
me to submit columns to their Health Leadership Forum, and I have done
so on an occasional basis since them. As I recently reviewed the
columns, I realized that my own thoughts on the topics of leadership and
coaching have evolved a bit, and I thought my readers over here at Not
Running A Hospital might enjoy witnessing the transition. So for several
days, I will be reprinting the posts from the Forum over here. Comments
are welcome at the original site and here. Today's reprint is from a post dated October 31, 2013, "Advocating Through Inquiry."

Here’s
a familiar story in America’s hospitals. An “old fashioned” surgeon
decides that the protocols and procedures put in place by the medical
executive committee or other governing body don’t apply to him. “I’ve
done it this way for 30 years, and it works fine. I’m the busiest
surgeon here, and no one is going to tell me how to do my job.”

People in the risk management field will advise you that such a
person is a high risk. His attitude often carries over to treatment of
people in the OR. At best, he is uncompromising and lacking empathy.
At worse, he is psychologically or perhaps even physically abusive to
lower level staff. He also tends to treat patients with a lack of
respect. He has more patient complaints on file compared to his peers.
When he finally makes a mistake that causes a patient harm, he is a
likely candidate for a large malpractice lawsuit.

And yet, notwithstanding this behavior, the hospital leadership is
unlikely to do much to correct the problem. The surgeon has a great
reputation in the community and is the source for many referrals. So, at
most, when an egregious incident is reported to his chief, the reaction
might be, “Yeah, I guess I won’t give him his full bonus this year.”

Clearly, such an approach is inadequate and will not resolve the
underlying problems. It fails because the message is not delivered at or
near the time of the incident. Also, there is not always a nexus drawn
between the financial penalty and the behavioral issue. Finally,
financial penalties do not have a lasting impact on behavior, if they
work at all.

Institutionally, we are advocates for greater adherence to clinical
approaches that are safer and deliver higher quality care. We also seek
behavior between doctors and colleagues—and doctors and families—that is
mutually respectful and reflects a partnership in delivering care. When
a doctor has been habitually misbehaving on any of these fronts, we
need a way to persuade him to change his ways.

Authority vs. Awareness Intervention

An alternative and more effective approach is outlined in several
articles by Gerald Hickson and others from the Vanderbilt University
School of Medicine. One article presents a hypothetical example about
an emergency room doctor who has misbehaved:

Dr. Trauma has high productivity. Nonetheless, you cannot offer
excuses for his performance. Others in the department conduct themselves
professionally. In addition, this is not the first time that Dr. Trauma
has behaved this way. During the past two years, other team members
submitted event reports that describe similar behaviors. Some of the
coworker and patient complaints suggest that Dr. Trauma gets angry in
pressured circumstances.

You previously spoke with Dr. Trauma about several
complaints from coworkers and patients. You find it concerning that Dr.
Trauma failed to self-correct after this feedback. Given the
accumulation of patient and staff complaints and the current event
analysis, you decide that what is right for Dr. Trauma and the
organization is for you, as his chief, to . . . require Dr. Trauma to
undergo a comprehensive mental health evaluation and, if indicated, a
defined treatment plan. Failure to comply would subject the physician to
a loss of privileges.

Certainly
this kind of “authority intervention” would get someone’s attention,
but hospitals are wary of this approach, in that it has the potential of
knocking a high performer off the clinical rolls. Also, chiefs often
have a personal relationship with the doctor in question, one that makes
it difficult to suggest that his colleague is medically impaired.

But Hickson, et al., also point out that a preliminary step can be
effective and help avoid the authority intervention. They term this an
“awareness intervention” by a peer. Awareness intervention is based on
the premise that “each professional has a responsibility that colleagues
and systems do no harm” and that “concerted effort to remove systemic
or behavioral threats to quality must include willingness to provide
feedback to others observed to behave unprofessionally.” It relies on
“sharing aggregated data that present the appearance of a pattern that
sets the professional apart from his/her peers.”

The key element of awareness intervention is to have a trained peer
“messenger” present the data (e.g., the high relative number of patient
complaints) and encourage the physician to reflect on what might be
behind that pattern, but not to provide directive or corrective advice.
The reason? “If a messenger offers a plan that does not ‘work,’ the
high-risk doctor can blame the plan and the messenger. We therefore want
messengers who promote ‘awareness’ and encourage self regulation.”

The Vanderbilt experience suggests that this form of intervention is
often successful. When it is not, the organization moves up the ladder
to the type of authority intervention mentioned above.

Some readers might be surprised that awareness intervention would
achieve any result. But let’s look at the underlying psychology. First,
doctors view themselves as scientists and can be persuaded by data.
Second, the troubled physician is treated respectfully. Third, the
remediation plan is not prescribed by another and therefore cannot be
viewed as externally imposed. It is his own creation based on his
understanding of his problems.

If we think about it more generally, though, the Vanderbilt approach
is based on an old theory of persuasion, one put forth by St. Francis:
“Grant that I may not so much … be understood as to understand.” Or as
Steven Covey restated it, “Seek first to understand and then to be
understood.”

Hickson and colleagues have designed a program that achieves advocacy
through inquiry. We stimulate the troubled doctor to consider the
reasons for his behavior and the results that stem from it. We ask him
to reveal his understanding of those reasons by designing and acting on a
plan to remediate them. We learn things about that doctor that can be
very helpful in our dealings with him but may also be useful more
broadly in our institution. Ultimately, through this process, he
understands, too, where we are coming from and adopts behaviors
consistent with the greater good. Our advocacy has succeeded.

Thursday, August 13, 2015

Over two years ago, the folks over at the athenahealth kindly invited
me to submit columns to their Health Leadership Forum, and I have done
so on an occasional basis since them. As I recently reviewed the
columns, I realized that my own thoughts on the topics of leadership and
coaching have evolved a bit, and I thought my readers over here at Not
Running A Hospital might enjoy witnessing the transition. So for several
days, I will be reprinting the posts from the Forum over here. Comments
are welcome at the original site and here. Today's reprint is from a post dated September 25, 2013, "Negotiating on Purpose."

After
her fifteen year-old son Lewis Blackman died from a series of
preventable medical errors, Helen Haskell diagnosed the problems in the
hospital by saying, “This was a system that was operating for its own
benefit.”

What she meant was that each person in the hospital was unthinkingly
engaged in a series of tasks that had become disconnected from the
underlying purpose of the hospital. They were driven by their
inclinations and imperatives rather than by the patient’s needs.
Indeed, they were so trapped in that form of work that they could not
notice the entreaties of a seriously concerned mother as her son
deteriorated.

I once heard a Harvard business professor describe the financial
imperatives of many hospitals in a less personalized, but analogous
fashion. He called hospitals “business cost structures in search of
revenue streams.”

What he meant was that the business strategies of the hospital had
become detached from the humanistic purposes that had led to the
creation of the hospital. There was thus a parallel to the individuals’
behavior noticed by Helen.

What
a perversion of human endeavor when things reach this point! Activity
for the sake of activity in the context of an organization that has lost
its soul.

Lest we get distracted by the current debate about the incentives
that might correspond to different payment models—fee for service,
bundled, or capitated rates–is important to note that this kind of
perverted personal and corporate behavior is not driven by rate design.
The failure of Lewis Blackman’s doctors and nurses had nothing to do
with financial incentives. No, the systemic forces at work that killed
this young man were based on ego, fear, poorly functioning hierarchy,
lack of communication, and cognitive errors.

Likewise, the corporate search for revenue for the entities that
constitute our hospitals and health systems has not been driven by rate
design. Under any payment regime, the underlying issue is that
hospitals are huge fixed-cost enterprises, and the incentive to “feed
the beast” often drives corporate strategy, driving out humanistic
concerns. Indeed, it may be that a movement to provider risk-sharing
will simply compound the problem in that it will require hospital
systems to accumulate greater financial reserves to hedge the actuarial
risks that are being transferred in their direction.

Let’s not lose the irony of this kind of situation. The people who
have chosen to be in the health care field are, for the most part, the
most well intentioned people in the world. They have devoted their
lives to alleviating human suffering caused by disease. They are
intelligent and thoughtful and highly trained.

Indeed, if each of us in health care were asked to state the purpose
of our institution in our own words, I bet we would say something
similar. In my former hospital it was codified as follows: “We hope to
take care of patients in the manner we would want members of our own
family cared for.”

People’s behavior in the moment, though, often is at variance with such purposes. Corporate imperatives likewise go awry.

It is at time like this that we search for leadership that will help
steer the ship and those in it in a more humanistic direction. Surely
the leader cannot be agnostic with regard to financial concerns, but he
or she needs to act to help the organization put purpose above all.
What can we expect and hope for from great leaders at this juncture in
medicine’s crisis of purpose? The usual answer—inspiration—is not
correct.

Professors often draw a distinction between management and
leadership, noting that leaders have the ability to inspire people in an
organization to a higher purpose. Yes, there is the kind of inspiration
that occurs during a crisis, like that offered by Winston Churchill
during World War II or Franklin Roosevelt during the Depression. But
for most organizations involved in the day-to-day work of providing a
service to the public, the professors’ description is off point, for the
leader’s ability to inspire is not germane. The ability to inspire
can provide a shot in the arm, but it seldom leads to sustained and
mindful action on the part of people in an organization in support of
its purpose.

My view is that inspiration comes from within and is tied to those
ethical standards and good intentions that caused people to enter the
health care professions in the first place. The leader’s job, then, is
not to inspire. It is to use his or her influence to help create a
supportive environment that permits the waiting reservoir of such
intentions to be tapped.

Paul O’Neill, former Secretary of the Treasury and CEO of Alcoa
Aluminum, has set forth a three-part test for an organization seeking to
empower its staff to fulfill its mission:

1. Are my staff treated with dignity and respect by everyone, regardless of role or rank in the organization?

2. Are they given the knowledge, tools and support they need in order
to make a contribution to our organization and that adds meaning to
their life?3. Are they recognized for their contribution?

The leader’s job is to carry out an ongoing negotiation with the
various constituencies in a hospital to persuade them that it is in
their interest to organize their work and behavior in such a manner as
to permit these conditions to take hold. You might find it strange that
I frame this responsibility as a negotiation, but that turns out to be a
more apt description than others that might be used.

Hospitals are filled with highly trained professionals who want to
spend their time doing the things they are trained to do. Those people
are not generally trained in the kind of interpersonal skills and team
behavior that is required to support Mr. O’Neill’s desired conditions.
The leader has to persuade those individuals that their own role will be
enhanced if they learn to behave in such a manner as will help develop
O’Neill’s conditions. In negotiation parlance, they have to be made to
feel that agreeing to such an approach is a better path than their
alternative, i.e., not agreeing to it.

People who are likely to be the future leaders of health care
institutions in America and abroad often come to me for career and
training advice. My constant refrain is to learn the principles and
framework of negotiation strategy. Negotiation can be defined as means
of satisfying parties’ underlying interests by jointly decided action.
You cannot be a leader if you do not know how to help a hospital’s
constituencies understand that their interests are coincident with the
purpose of your organization and if you cannot help them jointly decide
on the actions needed to carry out that purpose.

Wednesday, August 12, 2015

Over two years ago, the folks over at the athenahealth kindly invited
me to submit columns to their Health Leadership Forum, and I have done
so on an occasional basis since them. As I recently reviewed the
columns, I realized that my own thoughts on the topics of leadership and
coaching have evolved a bit, and I thought my readers over here at Not
Running A Hospital might enjoy witnessing the transition. So for several
days, I will be reprinting the posts from the Forum over here. Comments
are welcome at the original site and here. Today's reprint is from a post dated July 23, 2013, "Disclosure and Apology Must be taught Before they Can be Learned."

If
our objective as leaders is to gradually transform the health care
system to make it more patient-centered, we need to ensure the rising
classes of young doctors are trained to carry out this form of medicine.
Unfortunately, as noted by the Lucien Leape Institute, “[M]edical
schools and teaching hospitals have not trained physicians to follow
safe practices, analyze bad outcomes, and work collaboratively in teams
to redesign care processes to make them safer.”

As
Dennis S. O’Leary, MD, President Emeritus of The Joint Commission and a
member of the Institute has said, “Educational strategies need to be
redesigned to emphasize development of the skills, attitudes, and
behaviors that are foundational to the provision of safe care.”

Among the most important skills to be taught to doctors is how to
disclose medical errors to patients and families. Yet, training in this
topic is often relegated to a single lecture sometime during medical
school. Is there any question why the material doesn’t “take” when it is
treated so casually?

The great basketball coach John Wooden liked to say, “You haven’t
taught until they have learned.” How best to design a curriculum that
truly enables young doctors to learn the fundamentals of disclosure?

David Mayer, MedStar Health’s VP for Quality and Safety, is one of
the country’s leaders in undergraduate and graduate medical education.
He explains, “Disclosure training is a process, not a fifty-minute
lecture.” He and colleague Tim MacDonald developed the first four-year,
longitudinal patient safety curriculum for medical students in the
country. That curriculum started on the very first day of school at
8:30 a.m. He notes:

During the first half of the hour-long
session, I always asked the students to share with me the fears they had
on this first day of school, the starting point on their journey to
becoming a physician. Each year I did this, two fears rose to the top –
the fear of failure and the fear of hurting a patient. Students read
the newspapers that share personal stories of harm or talk about the
medical error crisis; many students had a family member harmed from a
medical mistake. As an educator, it was a great teaching moment to start
the safety conversation, and the reason why we started the conversation
on the very first day of school.

Over the years, the students were taught the “Seven Pillars”
disclosure and apology model developed by David and Tim for the
University of Illinois Hospital in Chicago. This model comprises a rapid
response to all unanticipated outcomes, full disclosure related to the
care, apology and early compensation, if warranted, and using
transparency and disclosure to learn from all our mistakes so that we
implement the necessary changes to our system to reduce risk to others. (The Seven Pillars approach was cited
by Agency for Healthcare Research and Quality [AHRQ] director Dr.
Carolyn Clancy and led AHRQ to fund a three-year project to spread the
model in 10 Chicago-area hospitals.)

For
the last two years, I’ve had the pleasure and privilege of joining
David, Tim, and other colleagues in Telluride, Colorado to conduct
week-long training programs for residents and medical students on this
and other aspects of disclosure and apology. What emerges is often a
cathartic experience for these trainees. Many have borne witness to
medical errors being committed in front of them, often by senior
residents or attending physicians. They bear the guilt of being afraid
to say anything that might arouse the wrath of their instructors. When
provided a safe environment with their peers and empathetic instructors,
they often tearfully relate their experiences.

Together, we design strategies that they can personally employ when
they return to their hospitals. But we also require them, as a condition
of attending our seminar, to design and carry out a safety-related
transformational project in their hospital.

The results from even this one-week session are impressive. Pharmacy
resident Quyen Nguyen stated: “One of the most important lessons I have
learned from the past three days is the urgency in which we need to act
to bring ethics back to the forefront of healthcare systems. Too often
the best interests of the patients and their families are put behind
financial, legal, and personal factors. It may never be possible to
prevent every error, but we have a professional duty to take
responsibility and put patients’ and their families’ needs first in the
aftermath of a medical error.”

Resident
Pat Bigaouette said, “The most important thing that I learned while in
Telluride was the importance of passion. I sat and listened as
passionate after passionate lecturer shared their experience and
expertise with me. I learned how they have all made a difference in
their respective healthcare systems by being enthusiastic and
passionate. I found myself going home and discussing patient safety for
hours after the conference had ended.”

Suresh Mohan returned to his residency program in Rhode Island and
noted: “Discussing my week with peers back home, I was shocked to
realize how little they knew (and, thus, cared) about the topic of
safety. I received responses of, ‘Well, I guess every field has its
downsides’ to ‘Whoa, I didn’t know you were, like, super into that
primary care stuff.’ It reaffirmed my decision to have attended, and the
value of what we learned.”

And Garrett Coyan left us all with an agenda: “The last week I spent
at Telluride was very eye-opening for me. Reinvigorated with ideas for
improving communication and decreasing risk to my patients, I couldn’t
wait to get back to my institution and start implementing change.
However, as I returned to the hospital today, I was quickly reminded of
the main reason why this goal will be so difficult. Not only does
cultural change need to occur in the hospital, but I would argue that
even more importantly, cultural change needs to occur in the education
of students in the health professions.”

There are steps in the education of young doctors that are our
obligation if we are associated with health care institutions. As David
Mayer notes: “The day has now come for greater accountability in medical
education around safety and quality.” In a series of blog posts, he has
set out the elements of an education program characterized by rigor,
thoughtfulness, and pedagogical excellence. If you are in a position to
influence the education program in your hospital, please read David’s
three posts by clicking the following: part one; part two; part three.
Then, use your leadership position to move your institution forward in
designing and implementing this kind of educational program for your
medical students and residents.

There is a potential bonus in all of this for hospital
administrators. It is well-documented that the incidence and size of
medical malpractice claims are reduced when physicians show empathy and
apologize after errors are made; when they accurately portray the nature
of what occurred; and, when they demonstrate that the hospital will
learn from the experience so that future patients might be spared the
same type of harm. Many older doctors are not adept at carrying out such
a disclosure and apology. Raising a new generation of doctors who are
skilled at this might therefore produce ancillary benefits for
hospitals.